A new report suggests that applying the American Board of Internal Medicine Foundation's Choosing Wisely framework could help decrease burnout among clinicians, including those in radiology and oncology. In JAMA Health Forum, a team of researchers recently provided an overview of the Choosing Wisely campaign, established by the American Board of Internal Medicine (ABIM) in 2012 (2022; doi:10.1001/jamahealthforum.2022.4018).
In addition to identifying health care services that patients and clinicians should consider ending due to limited clinical benefit, more than 80 clinician specialty societies across multiple health disciplines have generated more than 600 recommendations designed to help clinicians and patients choose care that is high value and avoid services that may be unnecessary or harmful, according to the investigators.
"Choosing Wisely has changed the national conversation about the need to reduce low-value care," the authors wrote. "Now, this decade-long quest to improve the value of health care delivery has collided with a demoralized health care workforce, creating a unique opportunity to improve health care work environments by applying a Choosing Wisely mindset to clinical management practices."
In the report, researchers noted that, in 2019, the National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being and Resilience recognized that the imbalance between clinicians' job demands and available resources was driving burnout in the health care profession.
Naturally, the coronavirus pandemic "has since underscored the scarcity of health care resources, including insufficient supplies and too few clinical personnel, a scarcity worsened by clinician burnout and resignations," the authors wrote, adding that the NAM has now published a National Plan for Health Workforce Well-Being, which includes approaches to addressing management and regulatory burdens among the several needed solutions to tackle clinician burnout.
With this report, the authors outline how to extend Choosing Wisely principles to identify clinical management practices that lead to unnecessary burdens; describe the partnerships between clinicians, health system leaders, regulators, payers, and policy-makers needed to reduce burdens; recommend a research agenda for evaluating the consequences of change; and propose approaches to identify and prioritize low-value practices.
For instance, the researchers point out the importance of identifying problematic practices as a first step, citing Hawaii Pacific Health's "Getting Rid of Stupid Stuff" program as an example. Through the program, the organization's employees nominate anything in the electronic health record (EHR) they feel was poorly designed, unnecessary or "just plain stupid," leading to streamlined documentation requirements.
The authors wrote that, by adapting Choosing Wisely principles, clinicians and health care leaders can identify these types of low-value management practices that put added, unneeded burdens on the clinician workforce; do not have a sufficient evidence base to improve clinical quality, organizational outcomes, or equity; do not address outcomes patients care about; and/or are duplicative or waste.
The researchers proposed three paths to identify and assess recommendations for choosing wisely to preserve clinicians, including those in radiation oncology.
"First, health care organizations can crowdsource nominations from clinicians for low-value clinical management practices that include and extend beyond the EHR," the investigators noted. "Organizations can triage the recommendations."
Second, health care leaders within and across organizations can endorse clinical management practices that should be abandoned without changes to external regulations and identify others that require regulatory reforms.
Third, as this process will identify existing practices of questionable utility because of external regulatory mandates-i.e., accreditation, safety, performance monitoring, payers-health care leaders should partner with regulators and stakeholders to change, scale back, or eliminate burdensome requirements and regulations.
The Choosing Wisely framework "provides a structure for clinical groups to crowd source clinical practices that, based on data, are of low value and questionable clinical benefit," noted Christopher Friese, PhD, RN, AOCN, Professor of Nursing at the University of Michigan School of Nursing, and one of the report's co-authors. "In oncology, examples include avoiding giving expensive anti-nausea medications when the chemotherapy regimen has a low- or medium-emetogenic potential," he noted.
The strength of the framework, he added, is that clinical experts-guided by review of pertinent clinical data-nominate the recommendations for their clinical specialty and the ABIM Foundation amplifies their recommendations on their website and subsequent publications.
"Here, we flip the script and focus on avoiding clinical practices that may be contributing to the alarmingly high rates of burnout we are seeing across cancer teams," Friese continued. "Two key differences from the usual framework include the need for more research on the negative impacts of administrative work and the need for systems and policymakers to provide regulatory relief to accomplish this work."
Friese and his co-authors encourage clinicians "to use our paper and the recommendations to launch discussions and action groups within their own practice setting to excise the administrative burdens that are not necessary, do not contribute to patient care, and result in increased work for all," he said. "I hope the oncology community actively embraces this work."
Mark McGraw is a contributing writer